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REPRINTED  FROM 

ANNAIvS  OK  SURGERY 

227  South  Sixth  Street,  Philadelphia,  Penna. 
September,  1920. 


THE  TREATMENT  OF  CHRONIC  EMPYEMA* 

By  Carl  A.  Hedblom,  M.D. 

OF  Rochester,  Minn. 

Definition. — The  word  empyema  is  from  the  Greek  signifying  a  collec- 
tion of  pus  in  a  cavity.  This  was  the  sense  in  which  the  word  was  used 
by  Hippocrates,  Galen,  ^tius,  and  others,  ^tius,  in  fact,  defined  the  term 
much  as  it  would  be  defined  to-day:  he  stated  that  those  persons  are  called 
"  empyici  "  in  whom  an  abscess  in  any  part  of  the  pleura  has  ruptured 
into  the  pleural  cavity.  Aretseus  Cappadox  wrote :  "  Those  persons  in 
whose  cavities  above,  along  the  region  of  the  chest,  or  in  those  below  the 
diaphragm,  abscesses  of  matter  form,  if  they  bring  it  up  they  are  said  to 
be  affected  with  empyema,  but  if  the  matter  pass  downwards  they  are 
said  to  labor  under  Apostemes."  Later,  Cselius  Aurelianus  and  others 
called  a  collection  of  fluid  anywhere  in  the  body  empyema.  Guy  de 
Chauliac,  1363,  defined  the  word  as  follows:  "  Empyma  or  empyema  in 
Greek  signifies  a  collection  of  pus  in  whatsoever  part  of  the  body  it  may 
be,  but  more  properly  used  meaning  a  collection  of  suppurative  matter  in 
the  testes,  thorax,  or  abdomen.  In  a  more  restricted  sense  it  means  pus 
in  the  thorax:  this  is  the  most  proper  and  common  significance.  Follow- 
ing it  one  calls  those  who  have  pus  in  the  thorax  *  empyes  '  or  '  em- 
pyiques '  in  Greek,  and  suppurants  or  purulents  in  Latin." 

Later  a  difiference  of  opinion  developed  as  to  whether  the  term  em- 
pyema should  be  limited  to  collections  of  pus  or  what  other  efifusions 
should  also  be  included.  Boerhaave  wrote :  "  Whenever  there  is  a  col- 
lection of  pus  between  the  lungs  and  the  pleura  in  the  cavity  of  the  chest 
it  is  called  an  empyema."  De  Sauvages,  CuUen,  and  others,  restricted 
the  term  to  pus  only.  Kisnerus  also  wrote  that  when  the  fluid  is  not  pus 
but  serous  (aquosa  simplex)  it  should  be  called  hydrops  of  the  chest.  It 
was  argued  by  others,  on  the  contrary,  that  what  was  blood  in  the  thorax 
may  have  changed  to  pus  and  that  therefore  collections  of  fluid  of  any 
kind  and  collections  of  air  should  be  included. 

The  drainage  operation  was  also  called  "  empyema  "  (Dictionnaire  des 
Sciences  medicales).  The  expression  "the  operation  of  empyema  was 
performed  "  was  of  frequent  occurrence. 

Leonus  Lunensis  (Dominicus),  1597,  used  "  empyemate  "  and  "  puru- 

*  Thesis  submitted  to  the  Faculty  of  the  Graduate  School  of  the  University  of 
Minnesota  in  partial  fulfillment  of  the  requirements  for  the  degree  of  doctor  of 
philosophy  in  surgery,  May,  1920. 

Abstract  read  before  the  Cleveland  Academy  of  Medicine,  February,  1920,  and 
before  the  American  Association  for  Thoracic  Surgery,  May,  1920,  New  Orleans. 

389 

C 0 lumb i a  Uiii  v^ r a  1  tv 


CARL  A.  HEDBLOM 

lentia  "  as  synonymous  for  fluid  occupying  sometimes  all,  sometimes  part, 
of  the  empty  cavity  of  the  thorax  (cavitate  vacua  pectoris). 

In  the  modern  use  of  the  term  tbe  word  may  still  be  defined  as  a  col- 
lection of  pus  in  the  pleural  cavity,  although  an  interlobar  empyema 
might  be  construed  to  fall  outside  this  definition.  In  the  transitional 
stage  between  acute  empyema  and  a  preceding  serous  effusion  the  dis- 
tinction is  a  matter  of  definition.  In  the  chronic  condition  the  effusion 
is  always  frankly  purulent. 

It  is  also  difficult  to  make  an  inclusive  definition  of  what  constitutes 
chronicity.  Certain  types  of  empyema,  those  with  large  bronchial  fistulas, 
those  with  cavities  at  the  apex,  and  some  of  uncertain  duration  at  the 
time  they  were  first  recognized  are  often  potentially  chronic  from  the 
onset,  in  the  sense  that  they  do  not  progress  to  a  cure  by  simple  drain- 
age treatment.  Perhaps  the  most  generally  accepted  criterion  of  chron- 
icity, however,  is  the  duration  of  the  process.  A  great  many  writers  con- 
sider an  empyema  of  six  weeks'  duration  to  be  chronic.  For  the  purpose 
of  this  discussion,  with  the  exceptions  noted,  three  months  are  taken  as 
the  time  limit  between  the  acute  and  chronic  condition. 

HISTORICAL   REVIEW 

The  history  of  empyema  up  to  the  last  three  decades  is  essentially 
that  of  chronic  empyema.  To  what  ancient  period  its  recognition  and 
drainage  treatment  date  we  do  not  know.  It  seems  probable  that  in- 
cision for  drainage  of  empyema  necessitas  was  done  by  the  Chinese  and 
Egyptians.  The  earliest  known  direct  references  to  the  condition,  now 
extant,  are  those  of  Hippocrates.  His  teachings  as  to  etiology,  symp- 
tomatology, prognosis,  and  treatment  contain  much  that  is  fundamental 
to  our  present-day  conception.  The  symptoms  and  signs,  as  he  stated 
them,  were  pain  in  the  chest,  high  fever,  cough,  distress  when  attempting 
to  lie  on  the  sound  side,  and  oedema  of  the  feet  and  of  the  eyes.  After  an 
illness  of  fifteen  days  the  patient  was  examined  for  fluid.  This  examina- 
tion consisted  of  shaking  him  by  the  shoulders  and  diagnosing  the  pres- 
ence and  site  of  fluid  by  the  splash.  If  no  splash  could  be  elicited  the 
side  in  which  the  pain  and  swelling  was  most  marked  was  considered  the 
one  affected.  Hippocrates  taught  that  the  matter  should  be  let  out  either 
by  knife  or  cautery.  If  there  was  a  swelling  externally,  he  directed  that 
an  opening  should  be  made  in  it,  if  not,  the  opening  should  be  made  at  the 
level  of  the  third  rib  from  the  last,  and  rather  behind  than  in  front.  He 
made  the  incision  superficially  with  a  large  bistoury,  then  continued  with 
a  lancet  wrapped  in  linen,  the  point  only  being  free,  or  used  a  trocar  or 
trephine  or  the  cautery  throughout.  After  some  of  the  pus  had  been  let 
out  he  closed  the  opening  with  a  tent  of  lint  attached  to  a  thread.  Every 
day  it  was  removed  and  pus  evacuated.  On  the  tenth  day  he  injected 
warm  wine  and  oil.  When  the  discharge  became  clear  and  glairy,  he  in- 
troduced into  the  opening  a  hollow  metal  tube. 

He  observed  that  patients  who  became  afifected  with  empyema  after 

290 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

pleurisy  recovered  if  they  got  clear  of  it  in  forty  days  after  the  time  it 
ruptured;  but  if  not,  it  passed  into  phthisis.  As  to  prognosis  he  stated 
that  if  pure  and  white  pus  flowed  when  empyema  was  treated  either  by 
cautery  or  incision,  the  patient  recovered ;  but  if  the  pus  was  mixed  with 
blood  and  was  stringy  and  fetid,  he  died. 

Euryphon,  a  contemporary  of  Hippocrates,  treated  empyema  with  the 
actual  cautery.  Celsus,  who  practised  at  the  beginning  of  the  Christian 
era,  is  the  author  of  our  next  most  ancient  reference.  He  wrote  on  the 
symptomatology  and  prognosis  much  as  did  Hippocrates.  He  stated: 
"  'Tis  common  for  fistulse  to  extend  beneath  the  ribs.  When  this  case 
occurs,  the  ribs  in  that  part  must  be  cut  through  on  both  sides  and  taken 
out  lest  anything  corrupt  be  left  within,"  and,  "  Fistulae  of  the  chest  are 
very  difficult  of  treatment,  so  that  sometimes  physician,  sometimes  patient, 
giving  up  hope,  leaves  the  case  to  Nature  herself." 

Pliny  related  the  story  of  a  soldier  with  empyema  whose  life  was 
despaired  of  by  his  physician.  Seeking  relief  by  death  in  battle,  he  was 
wounded  in  the  thorax;  the  pus  escaped  and  he  recovered. 

Leonidas  Alexandrinus,  a  Roman  physician  of  the  second  century, 
recommended  the  actual  cautery  for  effecting  drainage.  He  remarked 
that  his  contemporaries  feared  less  to  open  the  chest  by  the  cautery  than 
by  the  knife. 

Aretaeus  Cappadox,  of  uncertain  date,  probably  a  contemporary  of 
Galen,  said  concerning  the  pathology  of  empyema:  "  It  is  a  wonder  how 
from  a  thin,  slender  membrane  having  no  depth,  like  that  which  lines  the 
chest,  so  much  pus  should  flow ;  for  in  many  cases  there  is  a  great  collec- 
tion. The  cause  is  an  inflammation  from  redundancy  of  blood,  by  which 
the  membrane  is  thickened;  but  from  much  blood  much  pus  is  formed 
immediately.  But  if  it  be  determined  inwards,  the  ribs  being  the  bones 
in  that  region  *  *  *  I  have  said  above  that  another  species  of  phthisis 
would  naturally  occur.  But  if  it  points  outward  the  bones  are  separated, 
for  the  top  of  the  abscess  is  raised  in  one  of  the  intercostal  spaces,  when 
the  ribs  are  pushed  to  this  side  or  that." 

Cselius  Aurelianus,  who  lived  in  the  early  part  of  the  fifth  century, 
according  to  Haller  a  contemporary  of  Leonidas,  wrote  on  abscess  and 
empyema.  Buck  credits  him  with  being  familiar  with  ascultation  of 
the  chest. 

Galen  in  his  writings  emphasized  the  importance  of  providing  for  the 
escape  of  pus  in  the  thorax  in  order  to  avoid  the  ravages,  especially  of 
phthisis,  of  which  it  might  be  the  cause.  He  removed  portions  of  cari- 
ous ribs,  injected  warm  wine  into  the  cavity  (pectore),  and  urged  the 
patient  to  cough  while  leaning  toward  the  affected  side.  If  the  pus  and 
injected  fluid  did  not  thus  escape,  aspiration  was  done. 

Two  Greek  physicians  of  the  early  middle  ages  who  wrote  on  empyema 
are  lEims  and  Paulus  ^gineta.  Mims,  besides  giving  a  very  clear  defini- 
tion of  the  pathologic  condition,  stated  that  in  certain  cases  empyema  is 
formed  without  fever.     He  approved  of  the  cautery  in  its  treatment. 

291 


CARL  A.  HEDBLOM 

Paulus  yEgineta  wrote  a  compend  of  medicine  which  later  was  translated 
into  Arabic  and  Latin.  His  writings  on  empyema  were  based  on  the 
teachings  of  Hippocrates  and  Galen  but  showed  some  originality.  He  is 
quoted  by  Marcellus  Donatus  to  the  effect  that  cautery  or  incision  of  the 
thorax,  by  allowing  vitality  to  flow  out  with  pus,  causes  immediate  death 
or  an  incurable  fisula  results. 

During  the  latter  part  of  the  middle  ages  some  of  the  earlier  medical 
literature  was  preserved  by  the  Arabs.  Their  most  notable  contributor 
to  surgical  literature  was  Albucasis.  He  recommended  incision  or  cautery 
operation  for  drainage  of  empyema.  Avicenna  and  Avenzoar  also  ap- 
proved of  paracentesis  and  the  cautery.  Zacchias,  however,  said  that  the 
Arabian  physicians  feared  the  operation  for  empyema.  Lelorraine  said 
that  the  Arabs  disagreed  as  to  the  advisability  of  operation.  Nicolaus 
Massa,  while  granting  that  incurable  fistulse  might  be  left  after  operation, 
maintained  that  a  fistula  is  vastly  better  than  certain  death.  He  recorded 
a  case  of  draining  sinus  following  a  stab  wound  that  closed  after  seven 
years.  He  cited  the  case  of  a  girl  who  for  six  days  coughed  up  eight 
pounds  of  pus  daily,  and  ultimately  recovered. 

Guy  de  Chauliac,  besides  giving  a  definition  of  empyema  which  very 
closely  agrees  with  our  present  conception  of  the  disease,  mentioned  that 
the  operation  was  performed  by  his  contemporaries. 

Smetius,  1574,  reported  a  case  of  empyema  following  a  dagger  wound 
of  the  thorax.  An  incision  was  made  between  the  tenth  and  eleventh 
ribs  and  much  foul  pus  was  evacuated.  The  cavity  was  then  irrigated 
with  honey  and  water. 

Vesalius  taught  that  incision  should  always  be  made  for  empyema  and 
that  no  one  should  die  of  the  disease.  Certain  persons  would  die  be- 
cause of  their  wounds  and  not  because  of  the  operation.  He  referred  to 
several  cases  in  which  he  operated  successfully.  He  wrote  also  on 
thoracic  fistulse. 

Amatus  Lusitanus  was  one  of  the  first  of  a  considerable  number  of 
physicians  of  the  Renaissance  period  who  wrote  on  empyema.  His  is 
also  one  of  the  most  original  and  independent  expositions  on  the  subject. 
He  outlined  in  detail  the  teachings  of  Hippocrates  on  the  treatment  of 
empyema  and  discussed  the  relative  advantages  of  the  incision  and  the 
cautery.  With  regard  to  the  site  for  drainage,  he  pointed  out  that 
Hippocrates  ordered  that  the  drainage  should  be  made  as  near  as  possible 
to  the  septum  transversum  (diaphragm)  without  injuring  it.  As  to 
which  interspace  this  should  be,  he  said  that  rather  than  rely  on  the 
authority  of  Hippocrates,  he  determined  it  for  himself  on  the  cadaver. 
He  wrote : 

"  At  one  time  a  brother  of  Andreas  Vesalius,  the  renowned  anatomist,  in  mj-- 
presence  was  carefully  cutting  up  a  human  body.  Snatching  the  knife  with  which 
the  excellent  youth  was  dissecting,  I  made  an  opening  between  the  second  and 
third  ribs  on  the  left  side,  and  after  the  knife  itself  had  been  thrust  in  I  discovered 
that  the  '  septum  transversum  '  could  draw  no  harm  from  it.     However,  the  mad- 

292 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

ness  of  physicians  reaches  this  point  that  they  do  not  cut  between  the  second  and 
third  ribs  (counting  from  below),  but  rather  between  the  fourth  and  fifth,  or  if  it 
pleases  the  gods,  between  the  fifth  and  sixth,  although  they  cannot  draw  the  corrupt 
matter  easily  without  loss  of  the  patient,  since  the  pus  is  held  in  a  bag  and  they 
cannot  do  away  with  it  even  when  the  legs  are  raised  and  the  head  is  hanging  down." 

He  cited  a  successful  case  in  which  he  drained  between  the  third  and 
fourth  ribs. 

Marcellus  Donatus  had  a  case  of  empyema  necessitas  that  progressed 
to  a  spontaneous  cure;  he  remarked  that  almost  all  empyema  patients 
and  many  suffering  from  a  wound  penetrating  into  the  chest  died  because 
physicians  feared  to  cut  in  the  right  region,  an  operation  which  he  advised. 
However,  if  pus  would  not  drain  through  the  mouth,  he  believed  that  the 
opening  should  be  made  between  the  third  and  fourth  ribs  (counting 
from  below)  rather  than  lower  down,  on  account  of  the  danger  of  injury 
to  the  diaphragm.  He  added  that  the  incision  should  be  made  wherever 
pus  had  collected,  and  cited  many  authorities  for  the  statement  that  pus 
might  drain  through  the  urine.  He  spoke  also  of  perforation  of  the 
diaphragm  by  the  abscess. 

Leonus  Lunensis  (Dominicus)  gave  detailed  directions  for  the  medical 
treatment,  internal  and  external,  and  referred  briefly  to  the  use  of  in- 
cision and  cautery  in  cases  not  cured  by  such  treatment. 

Castellus,  in  his  treatise  on  the  diseases  of  the  thorax,  discussed  at 
great  length  the  external  and  surgical  treatment,  but  did  not  add 
anything  original. 

Fabricius  ah  Aquapendente  systematically  discussed  the  subject  and 
described  the  instruments  used  by  Hippocrates  and  by  Paulus  ^gineta. 
He  stated  that  most  persons  who  had  received  a  penetrating  wound  in 
the  thorax  had  to  wear  a  silver  tube  for  life  and  that  he  knew  of  patients 
who  had  carried  tubes  for  twenty  or  thirty  years.  Fistulae  persist,  he 
wrote,  because  of  the  constant  motion  of  the  chest,  because  the  pleura  is 
sinewy  and  bloodless,  and  because  of  the  tortuous  course  of  the  fistulous 
tract.  To  avoid  the  motion,  patients  should  be  in  bed  and  refrain  from 
work  and  all  speech,  from  wrath,  and  any  repressed  breathing  whatso- 
ever; second,  the  hard  skin  of  the  fistula  should  be  removed  either  by 
softening  or  corroding  or  burning  or  by  drug  or  by  instrument.  The 
pleural  cavity  could  also  be  closed  by  the  scar.  Furthermore,  all  corrup- 
tion must  be  removed  and  the  fistulous  tract  straightened  by  cutting  the 
curves  with  a  knife.  Fabricius  thought  that  the  rib  resection  operations 
recommended  by  Celsus  were  very  difficult,  dangerous,  and  cruel.  He 
was  of  the  opinion  that  a  rib  could  not  be  removed  without  tearing  the 
pleura  and  so  causing  the  death  of  the  patient.  He  recommended  a  curved 
silver  drainage  tube  and  treatment  of  the  fistula  as  though  it  were  a 
spring  and  not  an  ulcer. 

Zacutus  Lusitanus  published  records  of  three  cases.  In  the  first,  pus 
drained  by  the  urine;  in  the  second,  in  which  there  was  much  purulent 

293 


CARL  A.  HEDBLOM 

sputum,  the  patient  recovered  spontaneously  on  a  milk  diet ;  in  the  third, 
after  great  fear  and  misgiving  as  to  the  result  should  operation  be  under- 
taken, it  was  decided  to  be  guided  by  the  dictum  of  the  "  old  man  " 
(oraculum  senis).    An  incision  was  made  and  the  patient  recovered. 

Cases  were  reported  by  Horstius,  by  Tulp,  and  by  Jalon,  in  which  pus 
is  said  to  have  drained  by  the  urine,  and  in  Tulp's  case,  also  by  the  um- 
bilicus. Cures  following  operations  were  described  by  Kisnerus  and 
Riedlinus.  Operative  treatment  was  discussed  by  Zacchias,  Camerarius, 
Scultetus,  Fienus,  and  Fliccius.  Scultetus'  article  is  the  earliest  accessible 
reference  in  the  French.  He  discusses  indications,  time,  site,  technic,  and 
instruments  to  be  used  in  the  operation  of  paracentesis.  He  stated  that 
the  "  temperament  "  of  the  air  must  be  considered  and  cited  Hippocrates' 
recommendation  that  the  winter  and  summer  should  be  avoided  if  pos- 
sible on  account  of  the  sudden  changes  in  the  air  at  these  seasons.  He 
also  mentioned  that  a  purulent  effusion  is  in  need  of  earlier  drainage  than 
a  hydrops  on  account  of  the  rapid  increase  in  amount  and  the  ulceration 
produced  by  the  latter.  He  believed  that  of  all  sites  for  drainage  the 
seventh  interspace,  recommended  by  Hippocrates,  is  the  best  because  it 
furnishes  the  most  dependent  drainage.  He  recommended  injections  of 
wine  and  oil  after  operation. 

Fienus  wrote  on  paracentesis  for  empyema.  This  is  the  earliest  avail- 
able article  in  the  German.  He  defined  paracentesis  as  a  cut  through 
which  an  opening  is  made  into  the  body  cavity  (Hole  des  Leibes)  whether 
by  a  cold  iron  or  cautery.  He  discussed  in  a  most  interesting  manner  the 
problems  involved  in  pneumothorax  produced  by  this  operation. 

Fliccius,  after  citing  the  authorities  with  regard  to  suitable  location 
for  drainage,  decided  that  the  best  place  is  between  the  fifth  and  sixth 
ribs.  Kisnerus  wrote  that  venesection,  generally  a  most  excellent  remedy, 
is  almost  supreme  in  cases  of  empyema. 

Kinner  refers  to  blistering  (ustiones)  and  cites  ^tius,  who  directed 
that  empyema  patients  should  be  burned  about  the  neck,  back,  and  sides 
in  eight  places  in  all.  Kinner  stated  that  this  treatment  should  be  shud- 
dered at  and  that  it  was  easy  to  believe  .^tius  was  made  a  physician  from 
a  hangman  or  a  tormentor  rather  than  from  a  goldsmith. 

Wilhelm  ten  Rhyne  is  quoted  by  Riedlinus  as  stating  that  Japanese 
surgeons  inserted  the  leaves  of  India  fig  trees  in  empyema  patients. 

The  available  literature  from  the  eighteenth  century  is  essentially  a 
repetition  of  the  foregoing;  that  is,  citation  and  discussion  of  authorities 
and  a  few  isolated  case  reports.  Ingram  is  the  author  of  the  earliest 
available  treatise  in  the  English.  He  reported  a  case  successfully  drained 
and  took  issue  with  Sharp,  who  in  his  "  Operations  of  Surgery,"  Chapter 
XXIV,  says  that  the  operation  "  should  be  discarded  as  unnecessary 
when  blood  or  matter  is  fluctuating  in  the  thorax,"  and  confines  the 
necessity  of  it  to  "  cases  of  water."  A  few  other  successfully  operated 
cases  were  recorded  by  Springsfeld,  Valentin,  Gadiicke,  Carboue,  and 

294 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

others.  Koelpin  reported  a  case  of  pulsating  empyema  proved  at  opera- 
tion. A  few  spontaneous  cures  and  many  post-mortem  findings  are  re- 
corded by  Warner,  Fiirst,  and  Morin. 

Lapeyre  said  that  while  the  operation  for  empyema  is  known  to  all 
persons  of  the  art,  it  is  rarely  practised  because  of  the  uncertainty  of 
diagnosis  and  lack  of  assurance  as  to  success  of  the  operation.  He  be- 
lieved, however,  that  the  operation  should  be  done  oftener.  He  reported 
one  case  of  empyema  pointing  in  the  chest  wall  which  was  opened 
and  drained. 

The  greatest  impetus  to  advance  in  surgery  of  the  thorax  since 
Hippocrates  was  the  marked  improvement  in  diagnosis  by  the  art  of 
percussion  of  the  thorax  described  by  Auenbrugger  in  1761.  It  was  only 
after  several  decades,  however,  that  this  new  method  was  appreciated. 
The  great  clinician,  van  Swieten,  who  was  Auenbrugger's  teacher,  ignored 
it.  Stoll  was  the  first  to  mention  its  great  value  in  detecting  pleurisy 
and  especially  empyema,  in  order  that  operation  might  be  performed. 
Corvisart  and  Laennec^*'®  were  among  the  first  outside  of  Vienna  to  em- 
phasize its  importance.  Corvisart  translated  Auenbrugger's  treatise  into 
the  French. 

The  literature  of  the  first  eight  decades  of  the  nineteenth  century  is 
full  of  discordant  notes  with  regard  to  the  treatment  and  citations  of  pa- 
tients with  empyema  necessitas.  In  some  cases  the  cavities  ruptured 
spontaneously;  others  were  opened  by  simple  incision.  A  great  number 
of  necropsy  protocols  were  published. 

Hourelle,  1808,  wrote  that  in  the  advanced  stages  of  empyema,  in- 
ternal medication  is  at  best  useless  and  that  blistering,  scarification,  and 
fomentations  are  not  much  better.  He  stated  that  the  danger  is  not  in 
operation,  but  in  the  difficulty  of  applying  it  with  certainty. 

Burin  d'Aissard  stated  that  the  operation  had  been  feared  because  of 
the  misapprehension  that  air  in  the  chest  will  almost  always  kill  the 
patient.  He  was  of  the  opinion  that  when  a  fistula  results  it  should  be 
left  to  time  and  a  good  regimen. 

The  pessimistic  note  is  again  sounded  in  1825  by  Dumont,  who  said 
that  there  is  always  a  possibility  of  cure  by  spontaneous  absorption,  by 
thickening  of  the  pleura,  by  sclerosis,  by  absorption  by  way  of  the  urine 
and  bowels,  or  by  absorption  into  the  blood.  He  recommended  mercury, 
purgatives,  bleeding,  and  a  rigid  diet.  He  added  that  the  most  common 
termination  is  death. 

Rullier,  in  speaking  of  the  difficulties  of  diagnosis,  points  out  that 
Dionis,  Baffos,  and  Corvisart  all  opened  the  chest  without  finding  pus 
and  that  several  of  their  patients  died. 

Putegnat  laid  down  as  indication  foi  operation  acute  and  chronic 
dyspnoea,  local  and  general  oedema,  and  emaciation,  for  the  relief  of  which 
all  medical  remedies  had  failed. 

295 


CARL  A.  HEDBLOM 

Colson,  writing  on  empyema  following  a  perforated  wound  of  the 
thorax,  mentioned  the  professional  "  sucer  "  present  at  every  duel  ready 
to  draw  out  the  blood  from  the  wound.  So  successful  was  this  treatment 
that  it  was  thought  to  be  of  the  devil ;  and  in  one  case  a  priest  refused  the 
last  sacrament  to  a  wounded  man  thus  treated.  Bache  states  that  the 
cause  of  chronic  empyema  is  the  failure  of  lung  expansion. 

In  1834  Faure  reported  before  the  Academy  of  Medicine  in  Paris  a 
series  of  eight  cases  in  which  operation  had  been  performed.  Two  patients 
were  cured  and  all  the  others  improved.  This  report  precipitated  a  pro- 
longed discussion,  for  many  physicians  held  operation  in  disfavor.  Thus 
Barlow  stated  that  Andral  and  Louis  regarded  empyema  as  necessarily 
fatal.  Laennec  is  quoted  as  saying  that  the  operation  for  empyema  is 
rarely  successful.  Of  fifty  patients  treated  by  Dupuytren,  only  four  were 
cured.  When  he  himself  developed  empyema  he  refused  operation  and 
is  quoted  as  having  said  that  he  would  die  at  the  hand  of  God  rather  than 
with  the  help  of  the  surgeon. 

The  unsatisfactory  status  of  the  treatment  of  purulent  pleural  effu- 
sions is  strikingly  reflected  in  results  obtained.  The  greater  number  of 
case  reports  up  to  1834  were  those  of  empyema  necessitas ;  some  patients 
recovered  spontaneously  after  draining  (Malin  and  Salomon,  Shortridge, 
Steinheim),  others  after  incision  (Heyser,  Claessens,  Cleland,  and 
Tourtuel).  A  few  cases  were  recognized  and  treated  before  the  chest 
wall  was  perforated  (Colegrove,  Martini,  Wolfly).  A  large  number  of 
operated  cases  ended  fatally  (Kilgour,  Cayol,  Bonnet,  and  many  others). 
Small  series  of  cases  were  reported  by  Chambers,  Oke,  Hartshorne, 
Niese,  and  in  1841  a  series  of  forty-three  collected  cases  by  Sedillot. 

Colson,  1876,  stated  that  the  use  of  syringes,  cannulas,  and  other  aspi- 
rating devices  employed  by  Dionis,  Anel,  Scultetus,  Bruer,  and  others, 
had  fallen  into  disfavor.  After  the  work  of  Bowditch,  in  1852,  the  aspira- 
tion method  again  came  into  vogue. 

Gimbert  reported  a  case  in  which  seventy-four  aspirations  and  lavages 
were  done,  followed  by  a  cure.  Bouchut,  in  1872,  told  of  one  patient 
tapped  fifty-eight  times  during  sixteen  months  and  another  one  hundred 
and  twenty-two  times  during  eleven  months.  In  one  instance  50  gallons 
of  "  matter  "  is  said  to  have  been  aspirated  during  four  and  one-half  years 
without  any  diminution  in  the  daily  amount.  Simmonds  found  that  in 
forty-eight  collected  cases  treated  by  aspiration  forty-two  were  unimproved. 

Although  the  ancients,  following  Hippocrates'  teachings,  probably 
diagnosed  and  operated  in  many  cases  of  empyema  in  the  acute  stage,  the 
later  operative  treatment  was  largely  for  empyema  pointing  in  the  chest 
wall.  Besides  the  cutting  and  cautery  operation  the  use  of  caustic  stone 
was  also  described.  Some  practised  burning  a  deep  hole  and  palpating 
the  bottom  of  it  for  pus.  In  1810  Aupepin  described  a  "  new  "  technic  for 
performing  thoracotomy  by  making  the  opening  in  the  skin  and  inter- 
costal tissue  at  slightly  different  levels.    The  valve-like  arrangement  so 

296 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

produced  was  designed  to  prevent  pneumothorax  after  the  withdrawal 
of  the  aspiration  tube. 

In  1881  Homen  published  a  series  of  ninety-one  collected  cases  of 
patients  treated  by  incision  and  published  by  seven  different  authors  be- 
tween 1868  and  1876.  Of  this  group,  47.25  per  cent,  of  patients  were  cured, 
23.08  per  cent,  had  residual  fistulas,  and  29.67  per  cent.  died.  Fifty  per 
cent  of  52  of  these  patients  who  had  irrigation  in  addition  to  incision 
were  cured,  17.31  per  cent,  developed  fistulas,  and  32.69  per  cent.  died.  In  a 
larger  series  of  141  patients  the  mortality  was  33.33  per  cent. 

Rib  Resection  for  Drainage. — Rib  resection  in  empyema  is  mentioned 
by  Galen,  who  states  that  he  removed  pieces  of  rib  that  were  necrosed  in 
a  case  of  empyema  necessitas.  By  other  physicians  they  were  cauterized, 
removed,  or  let  alone.  No  mention  is  found  of  resection  of  a  sound  rib 
until  i860,  when  Walter  resected  the  eighth  rib  for  drainage  of  a  chronic 
empyema  caused  by  a  knife  stab  between  the  ribs.  The  fibrous  mem- 
brane was  removed  with  finger  and  spatula.  "  The  cavity  was  so  large  as 
readily  to  admit  the  head  of  a  child  a  year  old."  The  cavity  was  washed 
with  tincture  of  iodine,  zinc  sulphate,  and  decoctions  such  as  of  white 
oak  bark.  The  chest  wall  retracted  and  the  cavity  was  completely  obliter- 
ated in  the  course  of  a  year.  Roser  is  said  to  have  been  the  first  to 
propose  resection,  but  it  was  not  until  1865  that  he  performed  the  opera- 
tion. Peyrot,  Billroth,  Fraentzel,  Koenig,  Ewald,  and  others,  were 
among  the  first  to  perform  the  operation.  Weissenborn,  1876,  reported  a 
series  of  five  cases. 

Plastic  Operation  for  Obliteration  of  Chronic  Cavities. — According  to 
Peitavy,  Simon  first  recommended  rib  resection  in  order  artificially  to 
reduce  the  size  of  the  cavity  in  chronic  empyema.  Peitavy  published  the 
case  in  which  Simon  made  the  observation  that  the  cut  ends  of  the  re- 
sected ribs  approximated.  Simon  taught  this  idea  in  his  clinic  in  1869. 
Heineke  first  published  these  observations  in  1872,  in  his  "  Compendium 
der  Chirurgischen  Operations  und  Verbandlehre."  Kiister,  in  1877,  wrote 
that  in  chronic  cases  he  resected  one  or  two  ribs  in  front  of  and  behind 
the  fistula.  Letievant  reported  a  cure  in  a  chronic  case  and  emphasized 
the  fact  that  not  only  drainage  but  collapse  of  the  cavity  was  promoted 
by  rib  resection. 

To  Estlander,  however,  is  generally  accorded  the  credit  of  having 
directed  attention  to  the  principle  of  multiple  rib  resection  for  oblitera- 
tion of  chronic  cavities.  He  resected  a  sufBcient  number  of  ribs  com- 
pletely to  unroof  the  cavity.  In  his  first  communication,®^  in  1879,  he 
reported  six  cases.  In  a  later  report®*  he  emphasized  that  each  case  should 
be  dealt  with  according  to  the  condition  found  and  that  in  cases  with 
large  cavities  it  might  be  necessary  to  repeat  the  operation  a  second  or 
even  a  third  time.  Five  of  his  eight  patients  were  cured,  two  died,  and 
one  was  still  convalescing  at  the  time  he  wrote. 

Gallet  collected  the  first  100  cases  in  which  operation  was  performed 

297 


CARL  A.  HEDBLOM 

by  the  Estlander  method.  In  9  of  the  18  patients  who  died,  necropsy 
showed  large  cavities  with  collapsed  lungs.  Voswinckel  reported  the 
results  in  129  collected  and  6  personal  cases  of  multiple  rib  resection. 
Fifty-six  per  cent,  of  these  patients  were  cured ;  20  per  cent,  had  improved ; 
4  per  cent,  were  not  improved ;  and  20  per  cent,  had  died.  In  one  case  the 
results  were  uncertain.  Of  14  tuberculous  patients  included  in  this  series, 
8  died,  2  were  cured,  3  improved,  and  i  did  not  improve. 

The  plastic  operation  was  variously  modified.  Resection  of  seg- 
ments of  the  ribs  at  the  borders  of  the  cavity  through  parallel  incisions 
was  made  by  Tietze  and  others.  Wilms  strongly  advocates  this  method, 
especially  for  tuberculous  empyema.  He  calls  it  the  "  Pfeiler  Resec- 
tion." Jaboulay  and  Leymarie  resected  the  sternal  ends,  and  Boiffin" 
the  vertebral  ends  of  the  ribs.  Tietze  resected  the  ribs  as  for  a  Schede 
operation,  but  instead  of  excising  the  pleura,  tamponed  it  against  the  lung. 
He  stated  that  it  produces  a  concentric  pull  on  the  lung  and  diaphragm. 

In  1890  Schede  described  the  extensive  resection  that  bears  his  name. 
After  turning  up  a  skin  and  muscle  flap  of  larger  extent  than  the  cavity, 
the  whole  of  the  chest  wall  underneath  was  resected,  the  skin  muscle 
flap  being  then  allowed  to  fall  against  the  collapsed  lung.  He  stated  that 
in  case  the  cavity  extends  to  the  pleural  dome,  it  is  also  necessary  to 
resect  the  first  rib.  He  reported  10  cases  with  2  deaths,  and  later  389 
collected  cases  with  87.7  per  cent,  cures  and  12.3.  per  cent,  mortality.  Bergeat 
collected  134  cases  in  which  56.5  per  cent,  of  the  patients  were  cured;  4.5  per 
cent,  were  improved;  14.3  per  cent,  had  residual  fistulas;  1.5  per  cent,  were 
not  improved,  and  23.2  per  cent.  died.  Sudeck,  Depage,  Beck,  Helferich, 
Friedrich,  Sauerbruch,^^®  and  others,  attempted  to  lessen  the  duration  and 
shock  of  this  formidable  operation  by  dividing  it  into  stages  by  various 
modifications.  Sudeck,  Depage,  Friedrich,  and  later  Melchior  and  Goebel 
made  use  of  the  thickened  parietal  pleura  to  help  in  obliterating 
the  cavity. 

In  1892  Delorme  enunciated  a  new  principle  in  the  treatment  of  chronic 
empyema  cavities,  namely,  that  of  their  obliteration  by  reexpansion  of 
the  lung.  Previous  to  this  time  attention  had  been  consistently  centred 
on  the  chest  wall,  the  collapse  of  which  was  considered  the  only  means 
of  obliterating  the  cavity.  This  new  method  was  foreshadowed  by  Cornil, 
Oulmont,  Ehrmann,  and  others.  In  several  post-mortem  cases  in  which 
the  empyema  had  been  of  three  months'  to  a  year's  duration,  Oulmont 
was  able  to  double  or  treble  the  size  of  the  collapsed  lung  by  gentle 
insufflation.  Laennec^°^  also  expressed  the  opinion  that  the  reason  the 
lung  remained  collapsed  in  these  cases  is  because  of  the  limiting  mem- 
branes and  not  because  of  the  condition  of  the  lung.  Others,  on  the  con- 
trary, were  of  the  opinion  that  sclerosis  in  the  lung  tissue  or  inseparable 
adhesions  on  its  surface  preclude  any  possibility  of  reexpansion  of  the 
lung.  It  remained  for  Fowler  and  Delorme  to  prove  the  point  on  the 
living  patient.    Fowler  performed  his  first  operation  October  7,  1893,  and 

298 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

reported  the  case  December  30th,  of  the  same  year.  He  considered  the 
operation  adapted  to  non-tuberculous  cases,  and  concluded  the  article  as 
follows :  "  The  case  suggests  a  method  of  deahng  with  some  of  the  in- 
stances of  old  empyema  with  persistent  sinus  which  resist  all  means 
usually  employed  for  their  cure." 

In  May,  1892,  Delorme  dissected  off  the  parietal  pleura  more  than 
I  cm.  thick  in  a  patient  with  a  small  empyema  cavity.  The  expansion  of 
the  lung  that  resulted  suggested  to  him  the  possibility  of  obHterating 
large  cavities  by  a  similar  procedure.  In  June  of  the  same  year  (1892), 
before  the  Academy  of  Medicine,  and  in  April,  1893,  at  the  Surgical  Con- 
gress, he  proposed  the  method.  January  20,  1894,  Delorme  first  per- 
formed the  operation  in  a  case  of  empyema  of  four  and  one-half  months' 
duration,  and  obtained  complete  expansion  of  the  lung.  To  Delorme, 
therefore,  belongs  the  credit  of  first  having  enunciated  the  principle  and 
to  Fowler  the  credit  of  first  having  performed  the  operation.  In  1896 
Delorme  published  the  results  in  18  cases;  5  patients  were  completely 
cured;  2  were  improved;  and  8  were  not  benefited.  Delorme  recognized 
no  contraindication  to  operation  except  a  poor  general  condition  of  the 
patient.  He  wrote  that  tuberculosis  is  not  a  contraindication,  but  that  in 
its  presence  it  is  almost  impossible  to  secure  complete  obliteration  of 
the  cavity. 

Modifications  of  the  decortication  operation  as  first  described  by 
Delorme  and  Fowler  have  been  numerous.  The  most  important  one 
designed  to  conserve  the  chest  wall  was  the  introduction  of  rib-spreading 
exposure.  Roux  found  that  by  retracting  at  the  anterior  angle  of  an 
intercostal  incision  good  exposure  was  secured.  Sauerbruch^^'^  described 
an  improved  technic  with  subsequent  suture  around  the  ribs  for  air-tight 
closure.  Friedrich  and  others  have  used  rib  retraction.  LilienthaP^^  sec- 
tioned the  ribs  in  addition  to  spreading  them.  Boiffin^^  used  a  posterior 
incision  to  secure  access  to  the  paravertebral  space.  Quenu  and  Soubottin 
sectioned  the  entire  thickness  of  the  chest  wall  anteriorly  and  posteriorly, 
but  without  removing  the  ribs.  Krause,  Jordan,  Goullioud,  and  others 
did  extensive  resection,  practically  combining  the  Estlander  and  Delorme 
operations.  Ringel  and  others  combined  the  Schede  and  Delorme  pro- 
cedures. After  decortication  Lambotte  proposed  insufflation  of  the  lung 
through  a  preliminary  tracheotomy. 

Successful  case  reports  have  been  published  by  Bazy,  Battle,  Newton, 
Cotte,  Meyer,  and  Kiimmell.  Lund  reported  seven  cases  with  two  deaths, 
neither  due  to  shock.  Mayo  and  Beckman  reported  seven  cases,  with  one 
death.  They  expressed  the  opinion  that  the  operation  has  not  received 
the  consideration  it  deserves.  Dowd  reported  fifteen  cases;  fourteen  of 
them  were  in  children  whose  average  age  was  five  and  one-half  years. 
There  was  one  operative  death.  Dowd  wrote  that  in  extreme  cases  there 
are  many  disappointments  and  that  it  is  easier  to  secure  expansion  of  the 
lung  than  to  maintain  it.    LilienthaP^'^  reported  twenty  cases  with  three 

299 


CARL  A.  HEDBLOM 

deaths,  Whittemore  fifteen  cases  with  eleven  complete  cures  and  no  mor- 
tality. In  twenty-nine  cases  mentioned  by  Binnie,  seventeen  patients 
were  cured;  nine  were  not  improved,  and  three  died.  Violet  collected 
seventy-nine  cases.  Forty-eight  and  one-tenth  per  cent,  of  the  patients  were 
cured;  'j.J  per  cent,  were  improved;  31.7  per  cent,  were  not  improved,  and 
1 1.4  per  cent.  died.  One  case  was  not  completed.  Kurpjuweit  reported  fifty- 
six  collected  cases.  Thirty  five  and  seven-tenths  per  cent,  of  the  patients 
were  cured ;  19.7  per  cent,  were  improved ;  33.9  per  cent,  were  not 
improved,  and  10.7  per  cent.  died. 

In  a  case  in  which  it  was  impossible  to  separate  the  thickened  pleura 
from  the  lung,  Ransohoff  found  that  by  making  gridiron  incisions  about 
0.6  cm.  apart,  a  considerable  expansion  of  the  lung  was  obtained  owing  to 
wide  separation  of  the  cut  edges  of  the  pleura.  This  procedure  has  been 
used  since  quite  extensively  in  conjunction  with  the  various  modifica- 
tions of  the  plastic  operations. 

Lambotte  recommended  suturing  the  lung  to  the  parietal  pleura  after 
decortication,  if  the  lung  failed  to  expand. 

Kurpjuweit  advised  extensive  rib  resection  to  bring  about  expansion. 

Souligoux  proposed  cutting  the  thickened  membrane  at  its  reflection 
to  the  parietal  pleura,  thus  securing  mobilization  en  masse  if  the  lung 
failed  to  expand.  The  method  appears  to  be  practical,  however,  only  if 
the  lung  also  expands  at  least  in  part. 

Robinson  described  a  plastic  operation  for  closure  of  chronic  cavities 
posteriorly,  making  use  of  the  muscles  of  the  thoracic  wall  to  help  fill  the 
cavity.  Taddei  obliterated  a  cavity  by  transplanting  a  lipoma.  Beck 
obtained  very  good  results  by  the  use  of  skin  flaps  after  radical  excision 
of  the  roof  of  the  cavity.  He  has  also  reported  80  per  cent,  of  patients 
cured  in  150  cases  of  chronic  empyema  sinuses  in  which  bismuth  paste 
was  used. 

Irrigation  of  Chronic  Cavities. — The  use  of  irrigation  for  chronic  cavi- 
ties dates  back  to  Hippocrates.  He  directed  that  wine  and  oil  should  be 
injected  on  the  tenth  day.  Galen  and  Rhazes,  the  Arabian,  used  water 
and  honey.  Guy  de  Chauliac  employed  various  decoctions.  Evacuants 
and  detergents  were  used  by  Fabricius  ab  Aquapendente,  Ambrose  Pare, 
Dionis,  Willis,  and  others. 

Lamotte,  according  to  Massiani,  was  the  first  to  reject  all  irrigations. 
Opinions  have  differed  on  the  subject  ever  since.  Van  Swieten,  Ravaton, 
Maraud,  and  Pelletan  used  various  fluids.  Bell,  Chopart,  Desault,  and 
Lassus  condemned  the  practice  as  dangerous. 

Velpeau  advised  irrigation  in  encapsulated  cavities.  Boinet  and 
Boudant  recommended  chlorides  and  iodides,  and  Sedillot,  a  caustic  solu- 
tion, as  the  therapeutic  agent.  Since  that  time  a  great  variety  of  solutions 
have  been  used,  such  as  methyl  salicylate,  phenol,  creolin,  iodine,  saline 
solution,  hydrogen  peroxide,  boric  acid  and  carbolated  iodine,  corrosive 
subHmate,  and  "  purefied  air."    After  the  use  of  intrapleural  antiseptics 

300 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

fell  decidedly  into  disrepute,  it  was  renewed  again  by  J.  B.  Murphy,  who 
was  a  staunch  advocate  of  the  use  of  formalin  in  glycerine. 

In  the  available  literature,  the  first  mention  of  the  use  of  chloride  of 
lime  was  by  de  Brabant  in  1837.  Townsend  in  1845  recommended  a  "  weak 
solution  of  chloride  of  lime  as  an  antiseptic." 

Since  the  work  of  Dakin  and  Carrel  with  the  hypochlorite  solution, 
intrapleural  injection  has  come  into  favor  again.  Its  use,  however,  has 
been  largely  limited  to  acute  cases. 

GENERAL  CONSIDERATION  OF  PRINCIPLES  OF  TREATMENT 

From  the  foregoing  historical  review  it  is  found  that,  although  em- 
pyema has  been  recognized  and  treated  for  twenty-six  centuries,  it  is  only 
sixty  years  since  a  sound  rib  first  was  resected  for  drainage.  During  the 
next  thirty  years  attention  was  directed  solely  toward  collapsing  the 
thoracic  wall  for  obliteration  of  the  cavity.  The  most  radical  stage  was 
reached  in  the  complete  Schede  resection.  Since  that  time  the  trend  has 
been  toward  increasing  conservatism,  the  first  real  contributions  in  this 
direction  being  those  of  Delorme  and  Fowler.  It  has  also  become  more 
clearly  and  generally  recognized  that  there  is  a  considerable  variability  in 
the  pathologic  and  clinical  aspects  of  the  disease. 

The  first  essential  to  a  consideration  of  treatment  is  a  clear  conception 
of  the  cause  of  chronicity  and  of  the  pathology  involved.  Since  chronic 
cavities  and  residual  sinuses  are  often  but  different  stages  in  the  same 
case,  the  two  conditions  are  considered  together.  It  should  be  recognized, 
however,  that  each  may  exist  independently. 

The  most  common  causes  of  persistent  fistula,  apart  from  chronic 
cavities,  are  osteomyelitis  of  the  rib,  bronchocutaneous  fistula,  extreme 
sclerosis  of  the  walls  of  the  sinus,  foreign  bodies,  and,  occasionally,  tuber- 
culosis. The  common  causes  of  a  persistent  cavity  are  inadequate  drain- 
age ;  pneumothorax,  whether  from  early  open  drainage  or  from  a  ruptured 
subpleural  abscess  resulting  in  more  or  less  complete  collapse  of  the  lung 
not  yet  fixed  by  adhesions ;  too  late  drainage  after  the  lung  has  become 
fixed  firmly  in  a  collapsed  position;  persistent  bronchial  fistulas;  the 
presence  of  foreign  bodies;  reinfection;  and  tuberculosis.  Of  all  these 
factors  insufficient  drainage  is  the  most  common.  As  a  result  of  the  pro- 
longed suppuration  a  pyogenic  membrane  which  may  be  1.25  cm.  or  more 
thick  is  formed.  This  membrane  tends  to  prevent  expansion  of  the  lung 
even  after  the  primary  cause  is  removed.  Treatment  should  naturally  be 
designed,  so  far  as  possible,  to  remove  the  cause.  Dependent  drainage 
and  removal  of  necrosed  rib  or  foreign  material  are  simple  procedures, 
yet  they  often  bring  about  a  cure  after  years  of  chronicity.  If  a  bronchial 
fistula  is  present  its  closure  is  usually  a  prerequisite  to  healing. 

The  pathologic  condition  often  can  be  recognized  only  in  part.  Con- 
ditions of  the  lung  with  respect  to  tuberculous  and  other  sclerotic  changes 

301 


CARL  A.  HEDBLOM 

are  jften  difficult  to  determine.  If  an  extensive  pulmonary  tuberculosis  is 
present,  or  if  the  bacilli  are  demonstrated  in  the  pleural  exudate,  or  the 
typical  microscopic  picture  is  found  in  the  sectioned  pleura,  the  diagnosis 
is  established.  A  history  of  a  primary  pleurisy  with  serous  effusion,  later 
becoming  purulent,  is  also  at  least  very  suggestive.  Often,  however,  the 
history  and  findings  are  indefinite  and  uncertain.  Primary  tuberculous 
empyema,  secondarily  infected  by  injudicious  drainage  or  from  within, 
may  present  a  typical  picture  of  the  ordinary  suppurative  pleurisy. 

Whether  or  not  the  lung  is  capable  of  expansion  is  difficult  to  decide 
with  any  certainty.  Various  methods  to  ascertain  this  have  been  de- 
scribed, mostly  based  on  a  decrease  in  the  size  of  the  cavity  during  forced 
expiration.  Obviously  such  a  determination  may  be  more  a  measure  of 
the  relative  rigidity  of  the  thickened  pleura  than  the  elasticity  of  the  lung. 
Reineboth's  ingenious  method,  depending  on  the  changes  in  pulmonary 
circulation  that  result  in  increasing  the  intrapulmonary  pressure  in  a  lung 
that  is  still  expansible  but  in  which  changes  do  not  occur  if  expansi- 
bility is  lost,  unfortunately  has  not  so  far  proved  of  practical  value.  The 
mechanism  by  which  a  collapsed  lung  expands  is  of  much  practical  im- 
portance and  the  subject  of  much  difference  of  opinion.  The  presence  of 
an  intrapleural  pressure  less  than  atmospheric  and  the  reason  for  this  so- 
called  "  negative  "  pressure  is  an  elementary  fact  in  physiology.  It  is 
also  recognized  that  if  an  opening  is  made  into  the  pleural  cavity,  the 
lung  collaspses  from  equalization-pressure  on  the  two  sides  of  the  lung 
alveolus.  Other  factors  of  the  first  importance  to  the  clinical  application 
of  these  fundamentals  until  recently  have  received  but  scant  attention. 
/Among  such  factors  are  the  size  of  the  opening  in  the  chest  wall  in  rela- 
tion to  the  size  of  the  glottis,  the  presence  of  adhesions  between  the  lung 
and  the  chest  wall,  the  mobility  of  the  mediastinum,  and  the  vital  capacity. 
The  importance  of  the  relationship  between  the  opening  in  the  chest  wall 
and  the  glottis  was  recognized  by  Houston.  He  asked  van  Swieten  if  a 
person  wounded  in  both  sides  of  the  thorax  would  die.  On  being 
answered  in  the  affirmative  Houston  produced  a  small  normal  dog  on 
which  he  had  opened  both  pleuras  three  days  before.  This  astonished 
van  Swieten,  who  repeated  the  experiment  and  was  persuaded  that  when 
air  entered  the  two  pleural  cavities  the  wounds  were  fatal  only  if  the  two 
openings  combined  were  larger  in  area  than  that  of  the  glottis.  Later 
Cruveilhier  repeated  these  experiments.  It  remained  for  Graham  and 
Bell,  however,  to  point  out  the  great  importance  of  the  relationship  to  the 
treatment  of  acute  empyema.  They  showed  that  in  acute  cases,  owing 
to  the  mobility  of  the  mediastinum,  the  two  pleural  cavities  react  as  one 
to  changed  intrathoracic  pressure.  Lowering  or  neutralizing  the  nega- 
tive pressure  on  the  one  side  changed  the  pressure  the  same  on  the  other 
side.  Graham  showed  that  the  absolute  size  of  an  opening  in  the  chest 
wall,  compared  with  that  of  the  glottis,  depends  on  the  vital  capacity  at 

302 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

the  time.    Thus  a  man  with  healthy  lungs  can  withstand  a  much  Is'-ger 
opening  than  one  with  pneumonia  or  poorly  developed  lungs. 

These  considerations  are  of  fundamental  importance  in  the  treatment 
of  empyema.  The  large  number  of  variables  involved  explains,  at  least 
in  large  measure,  the  apparently  divergent  experiences  and  opinions  on 
the  subject  of  acute  pneumothorax.  In  chronic  empyema,  because  of  the 
fixation  of  the  mediastinum  and  the  presence  of  pulmonary  adhesions,  the 
two  pleural  cavities  function  independently.  For  this  reason  a  wide  open- 
ing on  the  affected  side  does  not  produce  respiratory  insufficiency. 

The  mechanism  by  means  of  which  the  lung  reexpands  has  been  vari- 
ously explained.  Roser  held  that  it  was  by  the  progressive  growth  of 
adhesions  along  the  margins  of  the  cavity,  the  contraction  of  which  pulls 
out  the  lung.  Weissgerber,  on  the  other  hand,  held  that  lung  expansion  is 
due  to  increased  intratracheal  pressure  during  expiration,  resulting  in  a 
summation  expansion  of  the  lung.  The  different  conceptions  are  reflected 
in  the  variety  of  devices  for  increasing  the  intratracheal  tension,  on  the 
one  hand,  and  for  decreasing  the  tension  in  the  pleural  cavity,  on  the 
other.  More  recent  opinion  is  also  divided.  Physicians  still  use  pleural 
suction.  Perhaps  the  majority,  however,  are  of  the  opinion  that  the  lung, 
when  free,  expands  essentially  because  of  the  increased  tension  from 
within  the  bronchi,  during  coughing,  straining,  or  other  effort  involving 
closure  of  the  glottis,  and  that  closed  drainage,  valve  action,  a  pus-soaked 
dressing,  and  the  like  are  used  chiefly  in  helping  to  hold  the  amount  of 
expansion  gained.  There  is  much  clinical  evidence  also  indicating  that 
progressive  adhesions  help  to  hold  the  lung  out,  once  it  is  expanded. 

Some  surgeons  believe  that  adhesions  are  always  detrimental.  Thus 
Lloyd,  on  the  principle  that  the  adhesions  tend  to  prevent  expansion, 
routinely  separated  them  at  operation.  He  reported  cases  of  225  patients 
treated  in  this  manner,  but  with  less  than  50  per  cent,  complete  cures  and 
20  per  cent,  mortahty.  Homans  has  expressed  the  belief  that  adhesions 
in  the  early  stage  are  often  the  cause  of  chronicity,  but  that  fixation  of  the 
lung  to  the  diaphragm  favors  expansion. 

In  chronic  empyema  the  greatly  thickened  membranes  prevent  the 
action  of  the  mechanism  which  brings  about  expansion  of  the  lung.  If 
these  membranes  are  removed,  incised,  or  disintegrated,  the  same  mech- 
anism again  comes  into  play,  provided  the  lung  has  retained  its  elasticity. 

At  operation  it  is  often  observed  that  when  the  patient  coughs  or 
strains  the  liberated  lung  expands  in  response  to  the  increased  intra- 
tracheal pressure.  In  the  after-treatment,  as  in  the  acute  condition,  the 
same  factors  favor  permanent  expansion.  In  the  cases  in  which  cavity 
obliteration  occurs  following  the  liberating  action  of  Dakin's  solution,  it 
can  be  determined  when  operation  is  performed  for  a  small  residual  cavity, 
that  the  lung  is  adhering  progressively  at  the  periphery  of  the  cavity. 
Dunham  observed  at  necropsy,  in  cases  in  which  Dakin's  solution  was 

303 


CARL  A.  HEDBLOM 

used,  that  the  walls  of  the  cavity  were  covered  with  granulations  favor- 
able for  adhesions,  while  in  those  in  which  there  was  no  treatment  a 
shaggy  fibro-purulent  deposit  was  found.  In  case  of  reinfection  these 
adhesions  tend  to  break  down  and  the  cavity  enlarges. 

Tuffier,  Stevens,  and  others  have  reported  series  of  cases  in  which, 
after  sterilization,  the  tubes  were  withdrawn  and  the  pneumothorax  left 
to  itself,  but  this  method  has  resulted  in  many  recurrences.  If  the  treat- 
ment is  successful,  the  lung  apparently  expands  in  proportion  as  the  air 
absorbs,  but  in  some  instances  cavities  have  persisted  for  months.  It 
seems  reasonable  to  believe  that  such  treatment  is  more  suitable  in  recent 
cases  than  when  the  condition  has  persisted  for  years.  To  what  extent 
an  increasing  pulmonary  circulation,  incident  to  deep  breathing  exercise 
and  other  effort,  aids  in  bringing  about  expansion,  can  not  be  stated,  but 
some  experimental  evidence  has  been  found  to  indicate  that  an  increased 
circulation  in  the  capillaries  tends  to  expand  the  lung  alveolus. 

In  cases  of  tuberculous  empyema  a  large  cavity  may  persist  for  years 
without  any  tendency  toward  lung  expansion.  At  operation  in  some  such 
cases  it  is  found  that  the  pleura  is  not  appreciably  thickened ;  the  failure 
to  expand  is  probably  due  to  a  fibrosis  of  the  lung  by  which  it  has  lost  its 
expansibility.  Fibrosis  seems  to  occur  also  in  long-standing  pyogenic  empyema. 

Aside  from  considerations  of  etiology  and  pathology,  the  guiding  prin- 
ciple in  the  choice  of  treatment  should  be  conservatism.  Chronic  em- 
pyema is  not  necessarily  incompatible  with  years  of  life  and  usefulness. 
In  such  cases  it  may  be  questioned  whether  radical  treatment  involving 
considerable  loss  of  function  is  ever  indicated.  It  would  certainly  seem 
difficult  to  justify  a  high  mortality,  particularly  if  a  safer  and  more 
effective  method  is  available.  Shortening  convalescence  is  often  men- 
tioned as  one  of  the  arguments  for  a  radical  procedure,  but  it  seems  that 
shortening  convalescence  does  not  justify  an  increased  mortality.  In 
the  choice  of  a  method  of  treatment  the  first  consideration,  therefore, 
should  be  the  life  of  the  patient,  the  second,  the  preserving  of  function, 
and  the  third,  the  shortening  of  the  convalescence. 

CLINICAL    STUDY   OF   CASES    AT   THE   MAYO    CLINIC 

In  49  of  150  cases  of  empyema  at  the  Mayo  Clinic  prior  to  1910  the 
Estlander  operation  was  performed;  in  9  the  Schede  resection,  and  in  i 
the  Delorme  decortication.  One  death  occurred  following  a  Schede 
operation.  The  210  patients  with  empyema  treated  between  1910  and 
November,  1917,  had  more  or  less  extensive  rib  resections.  A  Schede 
operation  was  done  in  six  instances,  a  decortication  in  seven,  and 
Ransohoff's  discission  of  the  pleura  in  one.  There  were  fourteen  deaths; 
one  followed  a  decortication. 

During  a  little  more  than  two  years  beginning  November,  1917,  150 
patients  with  chronic  empyema  have  been  treated  in  the  clinic,  with  a 
few  exceptions,  by  the  writer.    Eight  of  these  patients  had  sinuses  only, 

304 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

some  of  which,  however,  were  fairly  extensive.  The  others  had  chronic 
cavities  varying  in  capacity  from  50  to  2500  c.c.  One  hundred  and  seven- 
teen of  the  series  had  been  operated  on  elsewhere.  Most  of  the  others 
came  with  large  accumulations  of  pus,  variously  diagnosed.  One  boy  pre- 
sented himself  for  the  treatment  of  an  extreme  scoliosis  due  to  unrecognized 
empyema  of  probably  eight  years'  duration.  One  had  been  given  up  as  a 
hopeless  case  of  malignant  disease.  Unresolved  pneumonia  and  abscess 
of  the  lung  were  diagnosed  in  many  of  these  cases.  Fifteen  had  tuber- 
culous empyema.  Judging  from  the  history,  clinical  findings,  and  course, 
thirteen  others  may  also  have  been  tuberculous.  One  case  of  actinomy- 
cotic empyema  is  not  included. 

It  may  be  noted  that  three  months  are  taken  arbitrarily  as  the  time 
limit  between  acute  and  chronic  empyema.  In  some  patients  in  the  series, 
not  previously  operated  on,  the  date  of  onset  had  to  be  approximated 
from  the  history.  In  many  of  the  others,  in  which  the  duration  was  cal- 
culated from  the  date  of  a  late  operation,  it  was  probably  considerably 
longer  than  stated.  The  duration  of  the  empyema  by  periods  and  the 
number  of  cases  in  each  is  indicated  in  Table  I. 

Table  I 
Duration  of  Empyema 

Cases 

3  to     S  months 38 

6  to  12  months 47 

13  to  24  months 30 

2  to     3  years   12 

3  to     5  years  7 

5  to  10  years   11 

10  to  15  years   3 

15  to  20  years   i 

More  than  20  years  i 

ISO 

Table  H 
Age 

Patients 

Less  than  5  years 6 

6  to  10  years  S 

11  to  15  years  6 

16  to  20  years   24 

21  to  30  years  58 

31  to  40  years  34 

41  to  50  years  9 

51  to  60  years   7 

66  years i 

150 
306 


CARL  A.  HEDBLOM 

Only  eleven  were  children  under  ten,  yet  five  of  the  unrecognized 
cases  were  in  this  age  group.  In  one  of  these  the  diagnosis  had  been  first 
diphtheria,  then  scarlet  fever,  and  finally  typhoid  fever. 

Table  III 
Occupation 

Cases 

Farmer 54 

Business  man ^3 

Laborer   ^^ 

Housewife  9 

Student lo 

Carpenter    " 

Machinist 5 

Soldier  3 

Miner 3 

Railroad  man    9 

None  6 

Not  stated 2 

Miscellaneous 9 

150 

The  occupation  seemed  to  bear  no  obvious  relation  to  incidence. 

In  nineteen  cases  there  was  a  fairly  definite  family  history  of  tuber- 
culosis. Alcoholism  in  moderation  was  noted  in  thirty-seven,  and  in 
excess  in  three.  A  past  history  of  pneumonia  was  given  in  105,  in  sev- 
eral of  which  there  had  been  more  than  one  attack.  Pleurisy  had  been 
present  in  association  with  pneumonia  in  sixty-four,  and  was  primary  in 
sixteen.  A  serous  effusion  followed  pneumonia  in  two  definitely  tuber- 
culous cases.  In  eight  instances  of  primary  effusion  a  definite  diagnosis 
of  tuberculosis  could  not  be  made,  but  several  of  these  cases  ran  a  clinical 
course  characteristic  of  a  tuberculous  empyema  secondarily  infected. 

Table  IV 
Chief  Complaints 

Cases 

Draining    sinus    87 

Pain  in  chest 22 

Weakness    1 1 

Fever   7 

Cough 9 

Abscess  of  lung 6 

CEdema    4 

Arthritis    4 

150 
306 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

The  history  of  onset  was  given  as  sudden  in  io8  cases,  insidious  in 
thirty-two,  and  not  stated  in  ten.  The  etiologic  factors  stated  in  the 
history  were  as  follows : 

Table  V 

Etiologic  Factors 

Cases 

Pneumonia   65 

Pleurisy 15 

Influenza  38 

Trauma    8 

"  Cold  " 6 

Not  stated   7 

Miscellaneous    1 1 

150 

Pain  was  a  definite  symptom  in  sixty-five;  it  was  localized  in  the 
thorax  in  fifty-seven,  and  in  the  joints  in  four,  and  associated  with  res- 
piration in  six.  Marked  weakness  was  noted  in  fifty-five;  cough  was 
present  in  seventy,  absent  in  twenty-eight,  not  stated  in  thirty-two,  and 
was  associated  with  sputum  in  sixty.  The  sputum  was  profuse  in  eleven ; 
500  c.c.  in  three,  and  1000  c.c.  in  two,  these  being  cases  of  bronchial 
fistula.  Dyspnoea  and  pallor  were  noted  in  thirty-six  and  weakness  in 
fifty.  Haemoptysis  was  noted  in  four.  Loss  of  weight  was  a  fairly 
prominent  symptom. 

Table  VI 

Loss  of  Weight 

Cases 

Less  than  10  pounds 6 

II  to  15  pounds  7 

16  to  20  pounds  14 

21  to  30  pounds  14 

31  to  40  pounds   12 

41  to  50  pounds  2 

51  to  60  pounds   3 

61  to  70  pounds  2 

None 10 

Amount  not  stated  34 

No  mention  45 

.    ISO 

Fever  was  present  in  seventy-five  cases,  and  associated  with  chills  in 
twenty-two.  There  was  a  leucocytosis  in  two-thirds  of  the  cases  in  which 
a  count  was  recorded.    The  average  counts  were  as  follows : 

307 


CARL  A.  HEDBLOM 

Table  VII 

Leucocytosis 

Cases 

10,000  to  12,500    28 

12,500  to  15,000 17 

1 5,000  to  20,000 20 

20,000  to  25,000 14 

25,000  to  30,000 5 

30,000  to  40,000 2 

None 45 

Not  stated 19 

ISO 

A  persistent  high  leucocyte  count  was  frequently  observed  in  the  cases 
in  which  Dakin's  solution  treatment  was  used  without  fever  or  other 
symptoms  of  toxic  absorption.  A  secondary  ansemia  was  present  in  the 
majority  of  patients,  and  to  a  considerable  degree  in  about  a  third.  The 
averages  in  126  were  as  follows: 

Table  VIII 
Hcemoglohin 

Cases 

40  to  SO  per  cent 10 

50  to  60  per  cent 30 

60  to  70  per  cent 46 

70  to  80  per  cent 36 

80  to  90  per  cent 4 

A  low  blood-pressure  indicative  of  an  asthenic  condition  was  noted 
more  often  than  a  high  pressure.  No  significant  variation  was  found  be- 
tween systolic  and  diastolic  pressures. 

Table  IX 
Systolic  Blood-pressure 

Cases 

80  to    90  3 

90  to  100  15 

100  to  no  24 

1 10  to  140 77 

140  to  160  5 

160  to  180  I 

Not  stated  25 

150 
308 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

The  urinalysis  indicated  only  a  relatively  small  number  of  cases  with 
kidney  involvement,  even  though  the  average  duration  was  more  than 
one  year  in  sixty-five  of  the  cases.  On  the  basis  of  the  terminology  used 
in  the  Mayo  Clinic,  "  albumin  i  "  signifies  the  slightest  possible  trace 
demonstrable.    The  albumin  content  was  found  to  be  as  follows: 

Table  X 
Albuminuria  Graded  i  to  4 

Cases 

Grade  i   66 

Grade  2  25 

Grade  3  i 

Grade  4   i 

None  43 

Grade  not  stated   14 

150 

Bacteriologic  studies  of  the  exudate  at  operation  revealed  the  usual 
bacterial  flora.  Except  for  tuberculous  infection,  there  appeared  to  be  no 
clear  relationship  between  the  type  of  organism  and  the  severity  or  course 
of  the  process  in  these  chronic  cases. 

The  right  side  was  involved  in  eighty  cases  and  the  left  side  in 
seventy.  The  most  constant  physical  signs  aside  from  the  presence  of  a 
sinus  were  dulness  and  flatness  to  percussion  in  varying  proportion  and 
degree.    Dulness  was  noted  in  eighty-three  and  flatness  in  sixty-two. 

Limitation  of  respiratory  excursion  was  found  in  the  majority  of  cases. 

Fremitus  was  noted  in  the  area  involved  in  eight  cases.  Clubbing  of 
the  fingers  was  stated  to  be  present  in  nineteen  and  clubbing  of  the  toes 
in  one.  The  heart  was  displaced  to  the  right  in  fifteen  and  to  the  left  in 
nine.  A  palpable  liver  and  spleen,  indicative  of  a  degeneration,  was  noted 
in  five  and  six  cases,  respectively. 

The  clinical  diagnosis  of  the  presence  of  empyema  presented  little 
difficulty.  A  typical  empyema  is  most  apt  to  be  overlooked  in  children. 
Occasionally  an  encapsulated  empyema  with  a  large  bronchial  fistula  may 
be  quite  difficult  to  distinguish  from  an  abscess  of  the  lung.  In  some 
cases,  as  in  one  of  this  series,  both  were  present.  In  other  cases  in 
which  there  is  a  history  of  cough  with  large  amounts  of  sputum,  the 
differentiation  may  be  impossible  without  X-ray.  Three  patients  in  this 
series  with  such  symptoms  had  been  treated  for  months  for  abscess  of 
the  lung.  In  one  instance  an  empyema  had  persisted  for  years  without 
breaking  through  either  lung  or  chest  wall.  One  case  of  typical  empyema 
necessitas  simulating  an  acute  mastitis  was  observed.  The  clinical  diag- 
nosis supported  by  the  X-ray  examinations  in  this  series  was  as  follows: 

309 


CARL  A.  HEDBLOM 

Table  XI 

Clinical  Diagnosis 

Cases 

Chronic  empyema   ii5 

Effusion  or  empyema  with  tuberculosis 9 

Empyema  with  pneumothorax  7 

Empyema  with  bronchial  fistula 8 

Empyema  or  abscess   3 

Pleural  effusion   5 

Pneumonia   i 

Dermoid  cyst i 

Echinococcus  cyst i 

ISO 

It  will  be  noted  that  a  diagnosis  of  tuberculosis  was  made  clinically 
in  nine  of  the  cases,  but  the  tuberculous  lesion  was  in  the  lung  in  five ;  a 
tuberculous  effusion  was  specified  in  four.  A  diagnosis  of  a  pulmonary- 
lesion  was  made  in  three  additional  cases  by  the  Rontgen-ray.  One  of 
these  and  two  others  were  proved  microscopically.  All  of  these  patients 
gave  a  history  of  pleurisy  with  effusion.  Thirteen  other  patients  gave  a 
similar  history  of  a  primary  pleurisy  with  effusion.  Four  of  these  patients 
were  later  proved  to  have  a  tuberculous  infection  of  the  pleura.  Three 
who  were  shown  by  the  rontgenogram  to  have  pulmonary  involvement 
clinically  responded  very  well  to  treatment;  the  other  two  reacted  in  a 
manner  characteristic  of  a  tuberculous  empyema.  From  these  findings  it 
appears  that  while  both  a  pulmonary  lesion  and  a  history  of  a  preceding 
pleurisy  with  effusion  are  important  in  the  differential  diagnosis  of  a 
tuberculous  empyema,  a  pleurisy  with  effusion  is  probably  the  more  sig- 
nificant. A  tuberculous  empyema  may  run  its  course  without  any  clinical 
or  Rontgen  findings  to  suggest  the  condition  (Fig.  i). 

The  choice  of  surgical  treatment  for  chronic  empyema  has  been  be- 
tween simple  drainage  and  some  type  of  operation  designed  to  collapse 
the  chest  wall  or  to  expand  the  lung.  In  the  earlier  cases  in  this  series,  if 
a  cavity  of  any  size  persisted,  simple  drainage  was  first  tried,  followed  by 
a  decortication.  In  the  autumn  of  1918,  Dakin's  solution  was  first  used 
in  an  attempt  to  obtain  partial  sterilization  of  the  cavity  before  a  decorti- 
cation or  plastic  operation  was  performed.  It  was  then  discovered  that 
not  only  the  patient's  general  condition  was  improved  greatly,  but  the 
cavity  showed  an  unmistakable  tendency  to  reduce.  The  solution  was 
then  used  systematically  and  an  extensive  operation  performed  only  after 
the  hypochlorite  solution  treatment  had  been  tried.  If  operation  was 
indicated  for  a  cavity  of  considerable  size  in  a  non-tuberculous  case,  an 
attempt  was  made  routinely  to  obtain  expansion  of  the  lung  before  a 
collapse  operation  was  performed. 

310 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

Methods  of  Treatment. — The  methods  of  treatment  were  as  follows : 
(i)  Simple  rib  resection,  forty-two  cases;  (2)  Dakin's  solution  with  or 
without  minor  drainage  operations,  fifty-one  cases;  (3)  pulmonary  decor- 
tication, thirty  cases ;  and  (4)  plastic  operation  on  the  chest  wall,  twenty- 
seven  cases. 

1.  Simple  Rib  Resection. — Thirty-four  of  the  forty-two  patients  in  this 
group  had  been  operated  on  elsewhere.  Many  of  them  had  undergone 
several,  and  one  eleven  drainage  operations.  Among  those  who  had  not 
had  previous  operations  there  were  several  with  large  cavities.  Two  had 
bronchial  fistulse  and  were  emptying  the  contents  of  a  large  cavity 
through  the  bronchus.  Two  had  drainage  tubes  in  the  pleural  cavity,  the 
presence  of  which  had  been  unsuspected.  Faulty  drainage  was  the  rule ; 
the  drainage  opening  had  been  allowed  to  close  or  narrow  down  to  a 
sinus  before  the  cavity  had  become  obliterated,  or  the  opening  was  not  at 
the  most  dependent  point.  The  capacity  of  the  cavity  in  this  group  was 
less  than  250  c.c.  in  twelve,  between  250  and  500  c.c.  in  eight,  and  near  1000 
c.c.  in  two ;  in  one  the  lung  was  almost  wholly  collapsed. 

The  results  of  simple  drainage  operation,  not  counting  the  tuberculous 
cases,  were :  Complete  recovery,  twenty-six  cases ;  persistent  sinus  at  last 
report,  four  cases;  and  death,  one  case.  Eight  patients  could  not  be 
traced.  Of  the  tuberculous  patients  one  was  greatly  improved,  one  some- 
what improved,  and  one  was  not  benefited.  All  three  had  been  drained 
previously  elsewhere. 

2.  Dakin's  Solution  With  or  Without  a  Minor  Drainage  Operation  for  a 
Small  Residual  Cavity. — There  were  fifty-one  cases  in  this  group.  The 
technic  employed  consisted  in  the  insertion  of  a  catheter  through  the  old 
sinus  or  through  a  trocar  and  cannula,  aspirating  the  pus  and  irrigating 
with  the  sodium  hypochlorite  solution.  As  a  rule,  normal  saline  solution 
was  used  for  the  first  irrigation,  and  if  there  had  been  cough  with  sputum 
it  was  used  always  in  order  to  avoid  the  marked  bronchial  irritation  if  a 
bronchial  fistula  should  be  present.  Irrigation  was  performed  at  intervals 
of  from  one  to  three  hours.  Once  or  twice  each  day  the  cavity  was  half 
filled  with  the  solution,  which  was  aspirated  after  about  ten  minutes. 
Once  a  week  the  cavity  was  filled  by  gravity  and  the  capacity  noted.  In 
this  way  progress  was  measured.  The  patients  were  encouraged  to  use 
blow  bottles  and  other  devices  to  produce  increased  intratracheal  pres- 
sure. While  they  were  blowing  the  catheter  was  connected  with  a  tube, 
the  other  end  of  which  was  under  water  in  order  to  allow  the  air  to 
escape  as  the  lung  expanded  and  to  prevent  its  return.  The  patients  were 
given  setting-up  exercises  and  encouraged  to  be  outdoors  as  much  as  pos- 
sible besides.    A  generous  diet  was  prescribed. 

311 


CARL  A.  HEDBLOM 

Table  XII 
Results  of  Dakin's  Solution  Treatment  in  Fifty-one  Cases 

Capacity  of  cavity 


Average  number 
of  days 
of  treatment 


Capacity  of  cavity 

at  end 

of  treatment 


Average  decrease  in 

capacity  of  cavity 

per  cent. 


Less  than  lOO  c.c 35.9 

100  to  250  c.c 34.1 

250  to  500  c.c 56.4 

500  to  1000  c.c 45.2 

1000  to  2000  c.c 32.0 


10  c.c. 

11  c.c.  to  27.5  c.c. 
II  c.c.  to  22.0  c.c. 

II    c.c.  to  22.0   c.c. 

80  c.c.  to  160  c.c. 


90.0 

89.0 

95-6 
97-8 
92.0 

Cases 

Complete  recovery    34 

Sinus  at  last  report  6 

No  late  report   6 

Convalescence  not  completed  4 

No  benefit  (tuberculosis) i 


Cases 

II 

16 

IS 

5 
4 


51 

A  large  portion  of  the  time  spent  in  treatment  was  for  the  final 
obliteration  of  a  cavity  after  it  had  been  reduced  50  to  75  per  cent.  (Figs. 
2  and  3). 

Besides  the  reduction  in  the  size  of  cavities  of  more  than  90  per  cent., 
there  was  a  striking  general  improvement  in  all  these  patients.  A  gain  in 
weight  of  from  i  to  2  pounds  each  day  for  a  period  of  two  or  three  weeks 
was  frequently  observed.  A  slight  amount  of  bleeding  and  occasionally 
some  cough  were  noted,  but  no  serious  complications.  The  hypochlorite 
solution  was  used  in  fifteen  patients  preliminary  to  pulmonary  decortica- 
tion. Six  were  treated  for  a  period  not  exceeding  three  weeks,  all  of  these 
showing  an  appreciable  decrease  in  the  size  of  the  cavity.  In  the  other 
cases,  with  one  exception,  there  was  also  a  material  decrease  (Figs. 
4  to  12). 

Table  XIII 
Result  of  Dakin's  Solution  Treatment  Preliminary  to  Decortication  in  Fifteen  Cases 


Capacity  of  cavity 

Duration 

of 

empyema,  months 

Days 

of 

treatment 

Capacity  of  cavity 

at  end 

of  treatment 

360 

C.C. 

6 

9 

210 

C.c. 

500 

c.c. 

20 

ID 

200 

C.C. 

200 

C.c. 

21 

12 

100 

C.C. 

500 

c.c. 

6 

12 

180 

C.C. 

240 

c.c. 

4 

19 

ISO 

c.c. 

300 

c.c. 

4 

21 

240 

c.c. 

ISO 

c.c. 

3 

27 

150 

c.c. 

420 

c.c. 

15 

30 

390 

c.c. 

1000 

c.c. 

14 

32 

90 

c.c. 

ISO 

c.c. 

7 

42 

15 

c.c. 

1500 

c.c. 

3 

43 

100 

c.c. 

400 

c.c. 

4 

46 

30 

c.c. 

500 

c.c. 

6 

70 

60 

c.c. 

2000 

c.c. 

6 

75 

120 

c.c. 

2000 

c.c. 

14 

150 

240 

c.c. 

•312 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

Several  of  the  patients  in  this  series  would  not  have  withstood  an 
operation  of  any  magnitude  without  the  preliminary  treatment.  One  was 
a  girl  with  complete  collapse  of  the  lung  following  traumatic  empyema. 
She  was  reduced  from  120  pounds  to  73  pounds  and  was  brought  to  the 
cHnic  on  a  stretcher.  She  was  completely  cured  with  almost  full  re- 
expansion  of  the  lung.  Another  patient  had  an  almost  total  pneumo- 
thorax, a  complete  inhibition  Wassermann  reaction,  and  a  severe  grade 
of  nephritis  with  oedema.  His  blood  was  rendered  negative  to  the  Was- 
sermann test,  his  lung  reexpanded  about  90  per  cent.,  and  he  gained  about 
30  pounds  as  a  result  of  the  preliminary  treatment. 

3.  Pulmonary  Decortication. — There  were  thirty  cases  in  this  group. 
The  operation,  except  in  some  early  cases  before  Dakin's  solution  was 
employed  as  a  routine,  was  performed  only  after  the  antiseptic  method 
had  been  used  and  a  large  cavity  remained.  In  a  few  of  the  early  cases, 
only,  the  cavity  was  comparatively  small.  In  these  cases  in  which  it 
failed  to  obliterate,  it  had  been  rendered  relatively  sterile,  and  the  patient's 
general  condition  was  very  materially  improved. 

Decortication  was  done  under  general  anaesthesia  through  a  rib- 
spreading  exposure.  By  use  of  a  suitable  rib  retractor,  adequate  expo- 
sure was  obtained  without  cutting  the  ribs.  In  some  cases  in  which  the 
cavity  lay  very  high,  incision  was  made  in  the  sixth  or  fifth  interspace, 
cutting  the  scapula  across  and  resuturing  it.  Possibly  resection  of  the 
ribs  posteriorly  would  have  been  a  better  procedure.  The  thickened 
visceral  pleura  was  incised  and  separated  by  blunt  dissection.  In  many 
cases  the  preliminary  irrigation  had  softened  it  to  such  an  extent  that  the 
separation  could  be  done  very  readily.  If  cavities  were  large  a  complete 
visceral  decortication  was  done,  mobilizing  the  entire  lung.  In  one  case 
only,  of  primary  tuberculous  empyema,  it  was  absolutely  impossible  to 
separate  or  satisfactorily  to  incise  it,  but  partial  obliteration  of  the  cavity 
was  secured  by  mobilizing  the  lung,  as  first  suggested  by  Souligoux. 

Table  XIV 
Results  of  Decortication  in  Thirty  Cases 

Cases 

Complete  cure  without  further  surgery  15 

Complete  cure  after  secondary  plastic  operation  for 

small  residual  cavity 5 

Persistent  sinus,  last  report  3 

Death  following  operation  i 

Death  from  other  causes  several  weeks  after  patient  left 

hospital    3 

Under  treatment   3 

Two  of  the  three  patients  with  small  sinuses  were  tuberculous.     In 

313 


CARL  A.  HEDBLOM 

one  of  these  the  cavity  was  practically  obliterated.  The  patient  gained 
very  materially  in  weight  and  general  condition  following  operation.  The 
one  operative  death  was  due  to  a  streptococcus  pneumonia  occurring  dur- 
ing an  influenza  epidemic.    Two  of  the  patients  who  died  several  weeks 


c.c. 
500, 

475 ' 

450 

425 

400, 

375 

\ 

350  < 

i 

\ 

325 

\ 

\ 

300, 

\ 

\ 

275 

V 

250, 

\ 

225 

1 

) 

• — i 

k 

200, 

\ 

1 

1 

175  , 

Mji 

. 

N 

^^ 

150  i 

u 

» 

^ 

V 

125 

^ 

\ 

TOO  I 

, 

\ 

75 

^ 

^ 

In. 

50 

b^ 

^ 

^y 

K 

> — < 

^ 

■ 

25 

"^ 

^ 

►\ 

0 

\^ 

\hr<iH 

r^ 

M 

Weeks  12345      6789 

Fig.   2. — Twenty-eight  cases,  capacity  from  loo  to  500  c.c. 


after  operation  also  had  epidemic  influenzal  bronchopneumonia.  Necropsy 
in  one  of  these  showed  one  lung  expanded  and  an  empyema  on  the  other 
side.  The  third  patient,  in  whom  the  cavity  had  been  reduced  to  about 
30  c.c.  capacity  by  operation,  died  of  pulmonary  hemorrhage  seven  months 
later.     Tuberculosis  bacilli  were  found  in  the  exudate  and  tubercles  in 

314 


Fig.   I.   (Case  269926). — Unrecognized  empyema  probably  of  eight 

years'  duration;  cavity  obliterated  by  Dakin's  solution  and  minor 

drainage  operation. 


O   11 


o   ft 


ft  (U 

""ft 


S  J^  > 


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o 

■d 

p 

!B 

3 

& 

■< 

^ 

O 

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^ 

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2 

0 

tr 

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0, 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

the  pleura  shortly  before  death.    At  no  time  did  the  X-ray  show  any  evi- 
dence of  tuberculosis  (Figs.  13  to  17). 

4,  Plastic  Operation  Involving  the  Collapse  of  the  Chest  Wall. — Twenty- 
seven  patients  were  treated  by  this  method.    The  duration  of  the  disease 


c«c* 
1000  ' 

900 

800 

700  , 

600  « 

500  , 

1 

400  i 

|\ 

\ 

300 

\ 

\ 

200 

\ 

\ 

^— ( 

'-^l 

u 

X 

s 

^ 

100 

^ 

^ 

N 

K, 

^. 

'^ 

^ 

> i 

► 

t 

h 

!^ 

^ 

:=^ 

I 

► 

0 

Weeks    123456789 

Fig.  3. — Ten  cases,  capacity  from  400  to  1000  c.c. 


was  more  than  one  year  in  twenty-one  and  more  than  two  years  in 
eleven ;  in  one  it  was  of  twenty-three  years'  duration.  Five  patients  were 
definitely  proved  to  be  tuberculous ;  two  others  belonged  to  the  group  of 
primary  pleurisy  with  effusion  which  ran  a  course  suggestive  of  tuber- 
culosis.  Dakin's  solution  was  used  in  eight  patients  in  this  group  (Fig.  i8). 

315 


CARL  A.  HEDBLOM 


Table  XV 

/  Dakin's  Solution  Treatment  Preliminary 

to  PI 

Capacity  of  cavity 

Duration  of  empyema 

Days 

500  c.c. 

3  months 

22 

150  c.c. 

4  months 

55 

60  c.c. 

3  years 

57 

100  c.c. 

3  years 

35 

200    c.c. 

10  months 

30 

150  c.c. 

I  year 

9 

500  c.c. 

9  months 

47 

750  c.c. 

7  years 

90 

Capacity  of  cavity  at 
end  of  treatment 

120 

c.c. 

30 

c.c. 

45 

c.c. 

100 

c.c. 

60 

c.c. 

150 

c.c. 

30 

c.c. 

300 

c.c. 

In  nineteen  cases  the  solution  could  not  be  used  on  account  of  fistulas, 
or  they  were  early  cases  treated  before  the  solution  was  used  routinely. 

The  operation  involved  resection  of  the  ribs  over  the  entire  cavity, 
and  with  one  exception,  in  which  an  Estlander  operation  was  performed, 
excising  the  intercostal  tissue  and  parietal  pleura.  A  complete  Schede 
operation  was  not  found  necessary  in  any  case.  The  extent  of  rib  resec- 
tion was  reduced  in  the  majority  of  cases  by  the  skin  sliding  method  de- 
scribed by  Beck.  In  a  few  instances  a  skin-muscle  flap,  as  recommended 
by  Robinson,  was  made.  Resection  of  the  lower  angle  of  the  scapula  was 
necessary  in  three  instances  in  which  the  cavity  lay  directly  under  it.  In 
one  case  of  tuberculous  empyema  of  twenty-three  years'  standing,  the 
whole  chest  wall  was  resected  en  masse,  after  the  method  recently  de- 
scribed by  Peuckert.  In  another,  also  tuberculous,  the  Wilms  operation 
was  performed  in  three  stages. 

Table  XVI 
Results  Following  Plastic  Operation  in  Twenty-seven  Cases 

Cases 

Cure   15 

Residual  sinus  at  last  report 3 

Death  2 

Convalescence  not  complete 4 

Not  traced  3 

27 

Two  of  the  patients  with  persistent  sinuses  were  tuberculous.  In  one 
the  sinus  closed  after  many  months.  In  one  the  sinus  was  due  to  multiple 
bronchial  fistulas  with  an  associated  bronchiectasis.  The  closure  of  bron- 
chial fistulas,  as  I  have  mentioned,  is  necessary  to  the  cure  of  an 
empyema  cavity. 

The  cases  of  bronchial  fistulse  in  this  series  may,  for  convenience,  be 
divided  into  three  groups;  namely,  those  in  which  the  fistulae  closed 
spontaneously,  those  in  which  it  was  obliterated  by  operative  procedure, 
and  those  in  which  it  persisted. 

316 


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THE  TREATMENT  OF  CHRONIC  EMPYEMA 

In  the  first  group  are  a  number  of  cases  in  which  the  hypochlorite  solu- 
tion was  used.  A  bronchial  fistula  was  judged  to  be  present  if  the  pa- 
tient coughed  during  irrigation  and  at  the  same  time  tasted  the  solution. 
In  some  instances  these  symptoms  were  so  slight  and  transitory  that  the 
treatment  could  be  continued  provided  the  cavity  was  not  filled.  In 
others  irrigation  could  be  done  only  when  the  patient  assumed  a  certain 
posture.  Occasionally  it  was  necessary  to  substitute  saline  solution  for 
longer  or  shorter  periods.  In  a  considerable  number  there  was  slight 
bleeding  from  time  to  time.  In  no  case  was  the  bleeding  profuse.  In  a 
few  the  fistulas  were  observed  at  operation;  they  were  uniformly  small. 

In  the  second  group  are  the  ten  cases  in  which  the  fistulas  were  0.7  cm. 
or  more  in  diameter.  They  were  multiple  in  one  case  only.  Four  were 
due  to  perforation  of  large  unrecognized  empyemas  of  long  standing. 
These  closed  after  wide  open  drainage  was  provided.  In  one  case  of  ten 
years'  duration  a  large  fistula  was  found  at  the  costovertebral  angle.  It 
was  closed  by  an  extensive  resection  and  cauterization  of  the  tract.  In  an- 
other instance  the  scar  tissue  was  completely  removed  and  the  edges  of 
the  fistula  sutured  after  preliminary  cauterization.  The  remaining  four 
fistulas  were  closed  by  resection  of  the  ribs  and  thickened  pleura  fol- 
lowed by  skin  plastic. 

In  the  group  of  cases  with  persistent  bronchial  fistulas  were  two 
tuberculous  cases.  In  one  an  unsuccessful  partial  plastic  operation  was 
done ;  in  the  other  no  treatment  was  given  for  the  fistula.  A  third  patient 
had  twenty  or  more  bronchial  fistulas  in  the  same  lobe  of  the  lung,  with 
extensive  bronchiectasis.  Considerable  improvement  in  the  general  con- 
dition and  obliteration  of  most  of  the  fistulas  resulted  from  granulation 
tissue  proliferation  after  cauterization  (Fig.  19). 

RESULTS    OF   ALL   METHODS   OF   TREATMENT 

Table  XVII 
Summary  of  Results  of  Treatment  in  130  Cases  of  Chronic  Empyema 

?.'ettTn     -S^-     '^^'     c^Tfn     Total 
operation  treatment  operation   operation 

Cases  Cases  Cases  Cases         Cases 

Complete  recovery 26  34  20  15            95 

Residual  sinus  at  last  report 6  6  6  3            21 

No  report,  or  convalescence  not  completed..       8  10  3  7            28 

No  relief i  i  0  o              2 

Death* i  o  i  24 

Total    42  51  30  27  150 

Some  of  the  persistent  sinuses  followed  plastic  operations  for  tuber- 

*  Besides  the  patients  whose  deaths  were  recorded  as  operative,  four  patients 
died  after  leaving  the  hospital,  two  several  weeks  after  operation  of  streptococcus 
pneumonia;  one  died  seven  months  after  operation  of  tuberculosis,  and  one 
of  "  meningitis." 

317 


CARL  A.  HEDBLOM 

culous  empyema,  others  are  in  recent  pyogenic  cases  giving  promise  of 
complete  closure.  Practically  all  non-tuberculous  sinuses  can  be  obliter- 
ated by  plastic  operation.  Since,  as  experience  has  shown,  however,  that 
the  majority  of  the  sinuses  heal  spontaneously,  expectant  treatment  for 
a  limited  period  has  been  considered  justified  and  in  many  cases  advisable. 

Table  XVIII 
Operative  Deaths 

Cause  of  death  Operation  Cases 

Sepsis  and  inanition  Rib  resection  for  drainage  i 

Cerebral  abscess  Plastic  operation  i 

Tuberculous  meningitis  Plastic  operation  i 

Influenzal  pneumonia  Decortication  operation  i 


CONCLUSIONS 

From  the  study  of  the  literature  and  of  150  cases  from  the  Mayo  Clinic, 
the  following  tentative  conclusions  may  be  drawn : 

1.  Chronic  empyema  has  been  recognized  and  treated  during  twenty- 
six  centuries,  but  it  is  only  sixty  years  since  the  first  rib  resection  for 
drainage  was  done.  The  successive  stages  in  the  progress  of  treatment 
since  that  time  are  as  follows : 

(c)  Increasingly  radical  treatment,  designed  to  obliterate  the  cavity 
by  the  collapse  of  the  chest  wall,  involving  successively  more  extensive 
operations,  and  culminating  finally  in  a  complete  radical  resection. 

(b)  A  conservative  trend  manifested  primarily  in  the  modifications 
of  the  complete  resection,  but  more  in  the  attempt  to  preserve  the  chest 
wall  and  to  restore  the  lung  to  its  structural  and  functional  relationships 
as  first  advocated  by  Delorme. 

(c)  The  adaptation  of  the  Carrel-Dakin  hypochlorite  solution  technic 
to  the  treatment  of  chronic  empyema  cavities. 

2.  Chronic  empyema  is  a  disease  which  is  not  incompatible  with  life 
nor  with  a  fair  degree  of  health  and  usefulness.  The  principles  of  treat- 
ment should,  therefore,  be,  first,  the  preservation  of  life,  and  second,  as 
far  as  possible,  the  conservation  of  function.  Shortening  convalescence, 
while  very  desirable,  should  always  be  a  subsidiary  consideration. 

3.  The  choice  of  treatment  must  be  made  with  cognizance  of  the 
variable  etiology  and  pathology  of  the  process,  and  the  general  condition 
of  the  patient. 

4.  A  major  procedure  is  indicated  only  if  non-operative  or  less  exten- 
sive surgical  treatment  reasonably  may  be  considered  less  effective. 

5.  In  case  of  sinuses  and  small  cavities,  adequate  drainage  is  usually 
sufficient  to  eflfect  a  cure  with  or  without  short  preliminary  hypochlorite 
solution  treatment.     It  is  at  least  open  to  question  whether  a  radical 

318 


THE  TREATMENT  OF  CHRONIC  EMPYEMA 

operation  is  indicated  in  these  cases  for  the  sole  purpose  of  shortening 
convalescence  at  the  risk  of  an  appreciably  increased  mortality. 

6.  Dakin's  hypochlorite  solution  treatment  is  the  method  of  choice  in 
the  treatment  of  the  ordinary  type  of  chronic  empyema  cavity  of  any 
size,  for  the  following  reasons  : 

(a)  The  general  condition  of  the  patient  is,  as  a  rule,  improved  to  a 
remarkable  degree. 

(b)  The  cavity  may  be  obliterated  or  greatly  reduced  in  capacity  by 
the  liberation  and  expansion  of  the  lung  (resulting  from  the  treatment). 

(c)  If  the  lung  expands  in  part  the  extent  of  a  later  operation  will  be 
proportionately  reduced. 

(d)  If  the  lung  entirely  fails  to  expand,  the  cavity  will  have  become 
relatively  sterile  in  preparation  for  operation,  thereby  lowering  post- 
operative morbidity  and  mortality. 

(e)  Pulmonary  decortication  will  be  materially  facilitated  in  some 
cases,  owing  to  the  softening  action  of  the  solution  on  the  visceral  pleura. 

7.  A  pulmonary  decortication  through  a  rib-spreading  exposure  after 
preliminary  hypochlorite  solution  irrigation  is  the  most  conservative 
treatment  for  cavities  that  are  not  obliterated  by  drainage  or  Dakin's 
solution  treatment  alone.  If  such  an  operation  is  successful,  the  lung  is 
restored  to  its  normal  structural  and  functional  relationship,  thereby 
obliterating  the  cavity.  If  the  operation  is  only  partly  successful,  the 
magnitude  of  a  secondary  destructive  operation  is  proportionately  decreased. 

8.  Since  it  is  impossible  to  judge  with  certainty  before  operation  of 
the  relative  expansibility  of  the  lung  in  every  recent  non-tuberculous  case, 
a  decortication  should  be  done  rather  than  a  destructive  operation,  thereby 
giving  the  patient  the  benefit  of  the  doubt. 

9.  If  the  lung  does  not  expand,  or  if  a  considerable  cavity  persists  fol- 
lowing decortication,  a  plastic  operation  is  indicated. 

10.  If  the  cavity  is  of  considerable  extent  or  the  patient  debilitated,  a 
two-  or  three-stage  plastic  operation  is  to  be  recommended. 

11.  The  recognition  of  tuberculous  empyema  is  often  difficult.  A  his- 
tory of  a  primary  pleurisy  with  effusion  seems  more  often  to  signify  a 
tuberculous  condition  than  does  a  pulmonary  lesion,  unless  the  latter  is 
active  and  extensive,  A  tuberculous  empyema  may  be  present  in  the 
absence  of  clinical  or  X-ray  evidence  of  pulmonary  involvement.  The 
typical  microscopic  picture  in  the  sectioned  pleura  or  the  demonstration 
of  the  bacilli  in  the  exudate  may  constitute  the  only  evidence  in  such  cases. 

12.  A  tuberculous  empyema  not  secondarily  infected  should  not  be 
drained,  and  should  be  aspirated  only  for  a  considerable  accumulation  of 
fluid.  For  a  tuberculous  empyema  secondarily  infected,  either  by  opera- 
tion or  spontaneously,  drainage  is  necessary. 

13.  In  the  absence  of  bronchial  fistulas  and  of  bleeding,  secondarily 
infected  tuberculous  empyema  may  be  markedly  benefited  by  antiseptic 
solution  treatment.    The  amount  of  fibrosis  or  other  pathologic  change 

319 


CARL  A.  HEDBLOM 

in  the  lung  in  such  cases  determines  the  degree  of  expansion  of  the  lung, 
whether  following  antiseptic  solution  treatment  or  decortication. 

14.  If  the  lung  fails  to  expand  in  whole  or  in  large  part,  a  several- 
stage  operation  designed  to  collapse  the  chest  wall  is  indicated.  Tuber- 
culous patients  are  relatively  poor  operative  risks. 

15.  Adequate  drainage  is  the  first  indication  in  cases  of  empyema 
cavities  which  are  draining  through  large  bronchial  fistulas.  The  fistulas 
may  be  obliterated  spontaneously  following  such  treatment. 

16.  Operative  closure  of  bronchial  fistulas  that  persist  is  necessary  to 
complete  healing.  It  may  be  accomplished  by  decortication  of  the  in- 
volved portion  of  the  lung  with  cautery,  suture,  or  skin  plastic  to  cover 
the  opening  of  the  fistula.  Occasionally  healing  results  from  simple 
granulation  of  surrounding  tissue  after  destruction  of  the  epithelial  lin- 
ing of  the  bronchial  stoma. 

17.  Closing  the  bronchus  that  is  draining  pus  from  within  the  lung 
may  result  in  a  secondary  lung  abscess. 

18.  A  large  bronchial  fistula  is  a  contraindication  to  Dakin's 
solution  treatment. 

19.  Sinuses  of  variable  duration  are  common  following  more  or  less 
complete  obliteration  of  empyema  cavities;  a  large  proportion  eventually 
are  obliterated  without  radical  treatment ;  for  those  which  persist,  plastic 
operation  is  indicated. 

20.  Operative  mortality  in  chronic  empyema  has  been  due  largely  to 
shock  and  infection.  Reduction  of  the  extent  of  operation  and  prelimi- 
nary sterilization  will  materially  lower  this  mortality. 

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324 


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"'Melchior,  E. :  Ueber  die  plastische  Verwendung  der  parietalen  Pleuraschwarte 

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**  Rhyne,  Wilhelm  ten:  Quoted  by  Riedlius. 
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I'artere,  mammaire  droit,  gueri  par  I'operation  de  I'empyeme  au  lieu  d'election. 

Jour,  de  chir.,  1702,  iii,  iv,  108-115. 
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"^  Vesalius,  Andreas:  Quoted  by  Donatus. 
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Rippenresection.     Deutsch  Zeitschr.  f.  Chir.,  1897,  xlv.,  77-109. 
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336 


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^"  Weissgerber,  P.:  Wie  entfaltet  sich  nach  der  Operation  des  Empyems  die  com- 

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materias   spectantes  a  D.   Lanfranco  Zacchia  collectse.     Lugduni,   Buguetan 

and  Rau,  1661,  552  pp. 
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1637,  1 17-122,  160  pp. 


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